Basic Information
Provider Information | |||||||||
NPI: | 1164740577 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | D'VEAL FAMILY AND YOUTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | D'VEAL FAM & YTH BURBANK ELEM SCH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40255 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911147255 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262968900 | ||||||||
FaxNumber: | 6262968910 | ||||||||
Practice Location | |||||||||
Address1: | 2046 ALLEN AVE | ||||||||
Address2: |   | ||||||||
City: | ALTADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 910013424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6267986548 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2010 | ||||||||
LastUpdateDate: | 01/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCALL | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/D'VEAL FAMILY & YOURH SERVICES | ||||||||
AuthorizedOfficialTelephone: | 6267943136 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.